Proponents of the social-learning interpretation of gender-identity formation refer to various studies of intersexed children born with ambiguous external genitals who are assigned a particular sex and reared accordingly. Much of the early work in this area was performed at Johns Hopkins University Hospital by a team headed by John Money. When these treatment approaches were being implemented, Money and his colleagues believed that a person is psychosexually neutral or undifferentiated at birth and that social-learning experiences are the essential determinants of gender identity and gender-role behavior (Money, 1963; Money & Ehrhardt, 1972). Therefore, little attention was paid to matching external genitals with sex chromosomes. Rather, because the guiding principle was how natural the genitals could be made to look, many of these intersexed infants were assigned to the female sex, because surgical reconstruction of ambiguous genitalia to those of a female form is mechanically easier and aesthetically and functionally superior to constructing a penis (Nussbaum, 2000; Rosario, 2011).
Money and his colleagues followed these surgically altered children over a period of years and reported that in most cases children whose assigned sex did not match their chromosomal sex developed a gender identity consistent with the way they were reared (Money, 1965; Money & Ehrhardt, 1972). Additional evidence supporting these findings was recently published. Researchers surveyed 39 adult participants who had undergone surgical alteration as infants at Johns Hopkins. All of these individuals are genetic males who were born with a micropenis with a urethral opening on its underside. Some of the individuals were altered to be anatomical females and others to be anatomical males, with gender assigned accordingly. Most of these respondents (78% of women and
Gender Issues
76% of men) reported being satisfied with the gender chosen for them and with their body image, sexual functioning, and sexual orientation. However, 2 of the 39 switched gender as adults (Migeon et al., 2002).
Research has revealed that at least some intersexed children may not be as psychosexually neutral at birth as originally believed. Long-term follow-ups of several intersexed children treated under the Johns Hopkins protocol revealed that some of these individuals have had serious problems adjusting to the gender assigned to them (Diamond, 1997; Diamond & Sigmundson, 1997). One especially compelling account involved two identical twin boys, one of whom experienced a circumcision accident that destroyed most of his penile tissue. Because no amount of plastic surgery could adequately reconstruct the severely damaged penis, it was recommended that the child be raised as a female and receive appropriate sex-change surgery. A few months later the parents decided to begin raising him as a girl. Shortly thereafter, castration and initial genital surgery were performed to facilitate feminization. Follow-up analyses of these twins during their early childhood years revealed that, despite possessing identical genetic materials, they responded to their separate social-learning experiences by developing opposite gender identities. Furthermore, the child reassigned to the female gender was described as developing into a normally functioning female child.
If the story of these twins ended here, we would have strong evidence of the dominant role of social learning in gender-identity formation. However, a later follow-up (Diamond & Sigmundson, 1997) found that, beginning at age 14, still unaware of the XY chromosome status and against the recommendations of family and treating clinicians, this person decided to stop living as a female. This adamant rejection of living as a female, together with a much improved emotional state when living as a male, convinced therapists of the appropriateness of sex reassignment. His postsurgical adjustment was excellent and, aided by testosterone treatments, he "emerged" as an attractive young man. At the age of 25 he married a woman, adopted her children, and comfortably assumed his role as father and husband. This remarkable story is told in a book by John Colapinto (2000) titled As Nature Made Him: The Boy Who Was Raised as a Girl.
This case study illustrates the critical importance of long-term longitudinal studies of children whose sex has been reassigned. The early tracking during the childhood phase of this person was widely reported in the press and the academic and medical communities as providing clear evidence that gender identity is psychologically neutral at birth, as yet uninfluenced by social-learning experiences. Now, after many years during which this viewpoint predominated, we have learned in subsequent follow-ups how wrong this interpretation may be. Even John Money, formerly a major proponent of this perspective, moderated his position in later years (see Money, 1994b).
As a footnote to this famous case of apparent misapplication of the Johns Hopkins protocol, we mention another, underreported case with a different outcome. It concerns a boy whose penis was burned off during a circumcision procedure. This individual, also raised as a girl from infancy, was interviewed by professionals at ages 16 and 26. Although tomboyish as a child and bisexual as an adult, this person has maintained a female gender identity, unlike the more famous example of the twin who assumed a male gender identity as an adult (Bradley et al., 1998).
Another study has raised questions about the common practice of surgically assigning a sex to a child with ambiguous external genitals. This investigation reported on the development of 27 children born without penises (a condition known as cloacal exstrophy) but who were otherwise males with normal testes, chromosomes, and hormones. Twenty-five of the 27 underwent sex reassignment shortly after birth, by means of castration, and their parents raised them as females. All 25 exhibited play activities typical of males, and 14 eventually declared themselves boys. The two boys who were not reassigned and thus were raised as boys seemed to be better adjusted than their reassigned
counterparts. These results led William Reiner, lead researcher on this investigation, to conclude that "with time and age, children may well know what their gender is, regardless of any and all information and child rearing to the contrary" (Reiner, 2000, p. 1).
Several prominent researchers now argue that prevailing assumptions about gender neutrality at birth and the efficacy of sex reassignment of children may be wrong. In fact, more and more evidence has shown that, despite great care in rearing chromosomal males sex-reassigned as females, some—perhaps many—of them manifest strong male tendencies in their developmental years and may even change their assigned sex after they reach puberty (Colapinto, 2000; Diamond & Sigmundson, 1997; Reiner, 1997b). Concerns about the benefits and ethics of standard treatment practices used with inter — sexed individuals have provoked lively debate among intersexed individuals, researchers, and practitioners as discussed in the following section.
Treatment Strategies for Intersexed People: Debate and Controversy
People born with ambiguous external genitals are often viewed as biological accidents that need to be fixed. John Money and his colleagues at Johns Hopkins were the primary architects of a treatment protocol for intersexed individuals that became standard practice by the early 1960s and persists to the present. According to this protocol, a team of professionals, in consultation with the parents, choose which gender to assign an intersexed child. To reduce the possibility of future adjustment problems or gender confusion, the physicians usually provide surgical and/or hormonal treatments.
Questions have emerged about both the long-term benefits and the ethical appropriateness of this standard treatment protocol (Dreger, 2003; Fausto-Sterling, 2000; Gurney, 2007). Milton Diamond, an outspoken critic of John Money’s treatment strategies, has conducted long-term follow-ups of a number of intersexed individuals treated under this standard protocol. His research has revealed that some of these individuals experience significant adjustment problems that they attribute to the biosocial "management" of their intersexed conditions (Diamond, 1998; Diamond & Sigmundson, 1997).
The research of Diamond and others, and the testimony of people who have been harmed by treatment they have received via the standard protocol, has triggered an intense debate among intersexed people, researchers, and health-care professionals about what constitutes proper treatment of intersexed infants (Meyer-Bahlburg, 2005). Many specialists still support Money’s protocol and argue that intersexed infants should be unambiguously assigned a gender at the earliest possible age, certainly before the emergence of gender identity in the second year of life. This position endorses surgical and/or hormonal intervention to minimize gender confusion. An alternative viewpoint, championed by Diamond and others, suggests a threefold approach to treating inter — sexed people. First, health-care professionals should make an informed best guess about the intersexed infant’s eventual gender identity and then counsel parents to rear the child in this identity. Second, genital-altering surgeries (which later might need to be reversed) should be avoided during the early years of development. And third, quality counseling and accurate information should be provided to both the child and his or her parents during the developmental years to ensure that the child is eventually able to make an informed decision about any additional treatment steps, such as surgery and/or hormone treatments. A distinguished group of intersex researchers has strongly advocated delaying medical intervention until a child is old enough to have developed a male or female gender identity (Caldwell, 2005).
Both Diamond’s treatment strategy and the standard protocol raise important questions. Does genital-altering surgery performed on mere babies violate their rights as humans to give informed consent? Would intersexed children left with ambiguous genitals have problems functioning in schools or other settings where their condition might become known to others? Might society eventually evolve beyond the two-sex model
and embrace the legitimacy of a third, intersexed condition located somewhere on the spectrum between male and female?
A number of case studies have reported instances of people who comfortably adjusted to their untreated intersexed condition (Fausto-Sterling, 1993, 2000; Laurent, 1995). Furthermore, in recent years a number of intersexed people treated under the standard protocol have expressed strong resentment over being subjected to medical intervention as infants (Looy & Bouma, 2005; Rosario, 2011).
Intersex activists, who have established organizations such as the Intersex Society of North America (ISNA) and Advocates for Informed Choice (AIC), argue that inter — sexed people are cases of genital variability, not genital abnormality. The ISNA advocates a noninterventionist, child-centered approach in which an intersexed child is not subjected to genital-altering surgery; he or she may choose such procedures later in life (Caldwell, 2005; Tamar-Mattis, 2011).
More questions than answers exist about the most appropriate treatment strategy for intersexed infants. This uncertainty is due largely to a scarcity of long-term outcome studies on intersexed individuals (Meyer-Bahlburg, 2005). We hope that time and research will eventually resolve this dilemma.